Fetal Nutrition and Adult Disease: Programming of Chronic Disease Through Fetal Exposure to Undernutrition.

Fetal Nutrition and Adult Disease. Programming of Chronic Disease through Fetal Exposure to Undernutrition 

Langley-Evans SC, ed. CABI Publishing, Wallingford, UK, 2004, 433 pages, $262.00, ISBN 0-85199-821-6

CABI Publishing with the UK Nutrition Society is starting a series of books described as Frontiers in Nutritional Science. This is the second and fits the aim of the series, which is intended for advanced students, researchers, university teachers and nutritional health professionals. It also fits the other aim because foetal nutrition and adult disease is one of the active frontiers of nutritional science at present. Everyone is talking or writing about it, often with a very superficial understanding. Professor David Barker in the late 1980s presented evidence from follow up of series of babies with unusually careful birthweights that supported an idea that small-for-dates babies seemed to be more likely to develop cardiovascular disease in later adult life. Since then researchers in different countries have looked to see if they can (or cannot) confirm Barker's hypothesis (there could be confounding factors); which diseases are more likely, which less likely in people who were small or big babies, and what can be the mechanisms in the foetus? If foetal nutrition influences disease in adult life, there must be some sort of programming of the developmental processes, and this is the subtitle of the book.

The editor, Dr S.C. Langley-Evans has published many papers on changes in foetal rats exposed to maternal protein restriction and other stresses. He has assembled 16 chapters by clinicians, epidemiologists and animal researchers on the present state of knowledge about how well Barker's hypothesis has been confirmed in humans and about foetal deprivation in rats and sheep.

The chapters are all well-written scientific reviews on different conditions that can stress the foetus:hypoxaemia, maternal protein deprivation, undernutrition, endocrine imbalance, and on possible outcomes in adult life: renal disease, hypertension, insulin resistance, adiposity and diabetes. Some chapters also consider how much of any effect is due to postnatal as opposed to intrauterine stresses. One chapter even considers programming in the preimplantation embryo.

Among all the experimental data there were for me two outstanding reviews of the (human) epidemiology. Janet Rich-Edwards of Willett's group reviews cohort studies of birthweight and coronary heart disease or stroke. On the whole the 16 published studies usually showed more cardiovascular diseases in people who had low birthweight, but in some studies birthweights were recollected in adult life and the heightened coronary heart disease risk was mostly seen in those with rapid postnatal growth.

Rachel Huxley's chapter on birthweight and adult hypertension is the best analytical review of epidemiological data that I have yet seen. It reads like a detective story. She has a huge meta-analysis of 55 published studies. The small studies reported more striking associations (which is a worry) and the 'hypothesis generating group' found overall a four times greater effect (which is another worry) than other researchers. In the end she finds little support for a significant causal role of birthweight in the determination of blood pressure and cholesterol levels in adult life.

In contrast, there is no doubt, reported in other chapters, that different dietary deprivations of the mother affects programming in foetal rats, pigs and sheep that persists into adult life. This can happen without changing birthweight--a rather crude measure but all that is usually avoidable about the intrauterine conditions for human foetuses. However, the human foetus is much better cushioned from poor maternal diet than other species and does not appear to be very sensitive to variations in maternal diet. The effects of the Dutch 1944/1945 famine on those who were in utero at the time were rather unimpressive.

Here is an excellent book on this frontier of nutritional science. My two suggestions for future books in the series is that repetition could be reduced in the introductory paragraphs in the chapters and second, it would help readers to find their way around the book if there were structured summaries/conclusions at the end of each chapter.

A. Stewart Truswell

Emeritus Professor of Human Nutrition

University of Sydney